systems

I’ve gotten a few requests over my blogging time to talk about multiple personality disorder. I’ve (half) jokingly told friends that this post would garner me a great deal of upset commenters but here it is.

Important Note: My opinions on the scientific validity of this disorder DO NOT reflect any belief that identified ‘multiples’ or sufferers of DID aren’t suffering, don’t deserve to be treated, or should be in any way, shape or form ridiculed, belittled, or treated poorly. Full stop.

…and since this is a fairly prevalent feeling in the psych community, I’m less worried about the Internet is Forever ™ problem.

Sybil: a book, a movie, and a tale of really unethical psychology.

DID?

While there’s some reports of people exhibiting something like multiple personalities as early as the 17th century, but the diagnosis didn’t take off in popularity until the 20th century. It’s entry into pop culture is strongly linked to Sybil, a book about one (real) woman who appeared to have sixteen personalities. It was a popular book, run in newspapers, and cited as one of the main factors in the sudden upswing of DID/MPD diagnoses. Sybil and her therapist are no longer alive, but much criticism surrounds it. (See below)

DID/MPD was called Hysterical Neurosis, Dissociative type in the second iteration of the DSM. By DSM III it was Multiple Personality Disorder, and DSM IV made both significant changes to the criteria and the name, creating Dissociative Identity Disorder (DID). However, because of the prevalence of MPD in current literature/horror movies/culture, I’ll use DID/MPD.

In general, DID/MPD is characterized as having multiple distinct personalities or identities (this is the second required criteria for diagnosis). These are called ‘alters’. Usually, though not always, there’s a central personality that’s often treated as the “real” one. That identity is usually depressed or anxious.

So. Sybil.

Sybil is the pseudonym for Shirely Mason, the client of psychoanalyst Cornelia Wilbur. Mason didn’t come to her therapist because she had DID/MPD–her presenting problems were anxiety and memory loss. Then, after seeing Wilbur, suddenly, BAM, she had sixteen personalities.

Do I sound suspicious? I am.

Though the client files are sealed, multiple analyses of the taped sessions have said that Wilbur herself encouraged Mason to develop alters…and offered her money for talking about her different personalities. How did those personalities appear? Wilbur, who gave many drugs to her clients (including some very highly addictive psychotropics), gave Mason sodium thiopental and heard her mention other identities under the drug’s influence.

Sketchy? Most definitely. If that wasn’t damning enough, Mason wrote later that she had made the alters up.

Of course, Sybil/Shirely Mason being a the result of unethical practice doesn’t negate that multiple personalities could exist. So what else do we know?

Those with DID/MPD diagnoses are often reported as having severe trauma in childhood. Data on this isn’t actually very clear, because many of the psychologists to originally diagnose MPD/DID believed in repressed memories and used really unscientific techniques to ‘retrieve’ them (This was around the time of the satanic abuse cases). Current research doesn’t support the idea of this sort of trauma repression.

DID/MPD patients also score very highly in measures of ‘hypnotizabilty’–a specific measure of being suggestible…and anywhere between ‘many’ and ‘most’ practitioners who diagnose DID/MPD use hypnosis to determine if their clients have multiple personalities. Hypnosis: not a methodologically sound form of diagnosis.

And those practitioners? They’re a specific subset of psychologists, and they appear to get a statistically improbable number of clients who turn out to have DID/MPD. Of course, this could be a result of skeptic practitioners under diagnosing, right? Absolutely.

However as many as 70% of those with MPD/DID diagnoses appear to have borderline personality disorder (BPD). That’s high enough to suggest something more than simple co-occurence, which has lead to suggestions that professionals are using the idea of multiple personalities to explain the impulsivity and rapid emotional changes of BPD. Further, when the diagnosis of schizophrenia was introduced, there was a sudden crossover from those with MPD/DID to schizophrenia. Is it possible that those who believe in the DID/MPD diagnosis are just more likely to categorize BPD or schizophrenia as multiple personalities?

North America has the highest rates of DID/MPD diagnoses in the world. It’s also the place where multiple personalities are most familiar to the population at large. While this doesn’t mean the diagnosis is invalid, it casts, shall we say…aspersions. Secondly, when DID/MPD became a popular diagnosis in the 80’s, we also saw a sudden increase in the average number of alters, from 2-3 to an average of approximately 15. Hmmm.

Memory crossover in alters.

We’ve learned a lot about memory in the years since MPD/DID gained traction.We know, for instance, that repeated exposure to neutral (or even nonsense) words will result in faster recognition of those words.

(This can be tested by giving participants a series of possible categories for nonsense words and letting them learn by trial-and-error which word matches which category. For instance, in Trial One, James may match word Njdhsuf to Category A. When the result is NO, he is unlikely to try Category A for word Njdhsuf in Trial Two. By Trial Three, he may know that word Njdhsuf goes with Category C. If he is retested a short time later, James will sort the familiar nonsense words into their correct categories at higher rate than random chance, even if he feels as though he is guessing.)

Those diagnosed with DID/MPD report distinct personalities and identities, almost always reporting autobiographical amnesia (alters report knowing nothing of other alters or of what was done when the client was in a different identity) between personalities, one. So in a test like the one described above or similar, you would expect to see that if James is one identity, when he became an alternate identity, he would show no memory of the nonsense words, and sort them into correct categories at rates that resembled random chance. That’s not been shown to happen*. (This study also showed that indirect measures of behavior and ERP–which could be grossly oversimplified as how your neurons fire–found recognition in one identity of neutral words learned in different identity.) This study tested emotionally loaded words and found the same.

Okay, so what about autobiographical information? Though patients may have a central organizing identity, most report their personalities know nothing of other personalities. Objective tests have utterly failed to validate this. Though I strongly encourage reading this entire study about autobiographical memory in those with MPD/DID, here’s some relevant sections [bolding is mine]:

Consistent with previous studies, transfer between identities on the memory task occurred even for negative material, despite patients reporting amnesia for this material, learned in another identity state. Transfer across amnesic barriers in DID also occurs for conditioned emotional information. Testing DID participants, Huntjens et al. administered an evaluative conditioning procedure that confers a positive or negative connotation on neutral words. In a subsequent affective priming procedure, participants displayed transfer of this newly acquired emotional valence to the amnesic identity (i.e., transfer of emotional material between identities).

Our findings are consistent with the results of other studies involving objective laboratory tasks indicating intact inter-identity memory functioning in dissociative identity disorder. In most studies, researchers test memory within the same experimental session shortly after learning. In contrast, we tested memory after a 2-week delay, thus increasing the ecological validity of our study. However, the results do conflict with the reports of amnesia between identities, suggesting that the subjectively experienced absence of autobiographical knowledge about other identities is quite self-convincing.

I don’t have a great answer to this. Right now, therapy for DID/MPD seems to focus on integration: bringing all facets together into a single identity. There’s some pushback from self-identified multiples on this idea, many of whom feel that they’re not sick or broken, and that therapy treats them as such. I don’t really disagree, if they feel that they’re coping well. Forcing someone into therapy rarely goes well, and except in instances of danger to self or others, I’m all about the hands-off approach.

In the long term? I think we need to remove Dissociative Identity Disorder from the DSM. Like other diagnoses (*cough* Transvestic Fetishism *cough*) it seems to be the theory of a small contingent of scientists with little support in the community. When this dies as a cultural meme, I believe we’ll see a similar decrease in diagnostic popularity and even symptomology.. (We’re also seeing a sharp decline in scientific interest.)

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A great deal of the links and understanding that were required for this blog would not have been possible without Ed Cara, who you can find on twitter and blogging at The Heresy Club.

*Upon reflection this isn’t quite accurate. A few case studies have suggested autobiographical amnesia. However, I’m going to go with the majority of evidence found in studies that used controls (and simulators–people pretending to have amnesia) and larger pools of participants.

**Though DID/MPD has been a staple of the horror genre and several sensational trials, please don’t make the mistake of thinking DID/MPD is linked to being violent.

***This seems to be the preferred term in my reading of multiples’ writings (another popular term is ‘systems’). I’ll take correction and change this if I’m wrong.